A pilot study of the use of objective structural clinical examinations for the assessment of ophthalmology education.

PURPOSE: A pilot study was carried out to evaluate the practicality, reliability, and validity of an objective structured clinical examination (OSCE) for assessing the clinical skills and abilities of specialists in ophthalmology. METHODS: Ten unfolded OSCE style, criterion referenced questions were asked to nine candidates to assess their clinical skills and abilities, as opposed to subject knowledge. Candidate and assessor reactions to the examination process were monitored and analyzed using participant observation and questionnaires administered immediately after the event. Relevant statistical techniques were applied to the results. RESULTS: A total of 89% of candidates passed the examination, with the pass boundary set at 70%. Candidates revealed themselves more successful in meeting clinical skill criteria (mean 77%) than clinical ability criteria (mean 72%). Candidates, assessors, and observers all expressed the view that the OSCE pilot had been a successful way of assessing clinical skills and abilities. CONCLUSIONS: OSCE style assessment is an effective and efficient means of assessing skills and abilities in clinical ophthalmology education.

Nonpreserved human amniotic membrane transplantation for conjunctival reconstruction after excision of extensive ocular surface neoplasia.

PURPOSE: To report our experience on the use of nonpreserved human amniotic membrane transplantation (AMT) in ocular surface reconstruction after excision of extensive ocular surface neoplasia (OSN). DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: In all, 10 eyes of 10 consecutive patients with extensive OSN involving various areas of limbus, conjunctiva, and cornea (conjunctival carcinoma in situ, four eyes; squamous cell carcinoma, three eyes; malignant melanoma, two eyes; conjunctival-orbital lymphangioma, one eye) were included in this prospective noncomparative interventional case series. After excision of the neoplasia with 3-4 mm tumour-free margins, double freeze-thaw cryotherapy was applied to the margins of the remaining conjunctiva, and nonpreserved human amniotic membrane graft was sutured to the adjacent conjunctiva using 8/0 vicryl sutures and cornea using 10/0 nylon sutures, with the epithelial side facing up to cover the bare sclera and cornea. Postoperatively, topical corticosteroids were used for 3 months. RESULTS: After tumour excision and AMT, a satisfactory result with a wet, stable conjunctiva, and rapid and complete healing was observed in all eyes. Over a mean follow-up of 10.0 months (range, 6-27 months), all but one eye remained free of tumour recurrence. In one eye with conjunctival melanoma, there was a small recurrence, which was treated with excision and cryotherapy. Treatment complications were partial stem cell deficiency in two eyes and symblepharon formation in one eye. Immune graft rejection was not encountered. CONCLUSION: Nonpreserved human AMT appears to be useful for reconstruction of ocular surface following excision of extensive OSN.

Comparative efficacy of beta-irradiation and mitomycin-C in primary and recurrent pterygium.

PURPOSE: To determine the efficacy and safety of mitomycin-C as adjunctive treatment and to compare this drug with beta irradiation with strontium-90 after surgical excision of primary and recurrent pterygia. MATERIALS AND METHODS: The study group consisted of 193 patients with primary and recurrent pterygia who underwent surgical excision with the bare sclera technique. They were divided into two groups according to the type of adjunctive treatment. In group I, 130 patients (141 eyes, 67.8%) were treated with beta irradiation with Sr-90 doses of 1000-7000 cGy. In group II 63 patients (67 eyes, 32.2%) received topical mitomycin-C at a concentration of 0.02% four times daily for one week postoperatively. Recurrence rates, complications and efficacy of these treatments were compared with the chi-square of Fisher's exact test. RESULTS: The recurrence rates were 6.4% in group I after a mean postoperative follow-up of 89 months and 17.9% in group II after a mean follow-up of 14.9 months. Recurrence, rates and complications were higher in group II and the difference was significant (p<0.05, p<0.001). Life-table analysis showed a success rate of 93.6% for Sr-90 and 81.9% for the mitomycin-C, the difference being significant (p<0.005). CONCLUSIONS: Beta irradiation with Sr-90 after surgical excision was more effective than topical mitomycin-C in patients with primary and recurrent pterygium in terms of recurrence rates, and safer in terms of complications.

Amiodarone-related optic neuropathy.

BACKGROUND: To evaluate a case of atypical optic neuropathy that presented with blurred vision following the use of an antiarrythmic agent. CASE: Record of the patient was reviewed to determine the etiology of his optic neuropathy. OBSERVATIONS: Ophthalmological examination revealed unilateral optic disc edema with relatively well-preserved visual acuity. In routine tests, results of complete blood count, erythrocyte sedimentation rate, liver and kidney function tests, chest x-ray, Goldmann visual field examination, and brain computed tomography scan were normal. Orbital ultrasonography revealed optic disc edema with prominent optic nerve head and without orbital pathology. CONCLUSIONS: Systemic history and drug intake should be investigated in every patient with optic disc edema. Discontinuation of the medication can prevent further optic nerve damage or involvement of the other eye.

nm23 Expression in choroidal melanoma.

nm23 protein expression of choroidal melanoma was investigated to determine its relationship with clinical and histopathological characteristics of the tumour. Thirty-four consecutive choroidal melanoma patients were examined by immunohistochemistry. Although age, sex, tumour cell type, tumour size, pigmentation, necrosis, apoptosis and tumour lymphocytic infiltration were not correlated with nm23 protein expression, tumours with low percentages of nm23-positive cells revealed higher nuclear grades and predominant mitotic figures. nm23 may be associated with melanoma progression, but there is no proof that it plays a role in the metabolic process of the tumour.

Superior oblique muscle palsy in a patient with orbital dermoid cyst.

We describe the clinical and radiologic findings and surgical outcome of an orbital dermoid cyst causing a superior oblique muscle palsy in a child. Superior oblique muscle palsy in childhood is most often congenital. Less common causes are trauma, vascular lesions, neoplasms, and infections.(1,2) The most common orbital lesions in children are dermoid and epidermoid cysts.(3-5) A dermoid cyst at the region of trochlea is suspected as the cause of superior oblique muscle palsy in our case. This unusual presentation of a dermoid cyst has not been reported previously.

Colour Doppler imaging of the orbital vasculature in Graves' disease with computed tomographic correlation.

AIMS: To evaluate alterations in orbital blood flow parameters and their correlations with extraocular muscle enlargement, proptosis, and intraocular pressure in patients with Graves' disease. METHODS: In this multicentre study blood flow parameters in the ophthalmic artery, superior ophthalmic vein, central retinal artery and vein were determined by colour Doppler imaging in 111 patients with Graves' disease in two groups (A and B) and 46 normal control subjects. Group A consisted of 42 patients with Graves' disease without ophthalmopathy; group B of 69 patients with Graves' disease with ophthalmopathy as detected by orbital computed tomographic scanning. RESULTS: Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein in patients in group B were statistically significantly higher than those in group A and the normal controls, whereas maximal and minimal velocities in the superior ophthalmic vein in patients in group B were statistically significantly lower than those in group A and the control subjects. Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein also correlated with the sum of all extraocular muscle diameters in group B (r > or =0.31, p< or =0.021). Blood flow parameters had no consistent correlation with proptosis or intraocular pressure (p>0.05). No statistically significant difference was found in resistivity indices between the groups (p>0.05). Reversed blood flow was noted in nine (13%) superior ophthalmic veins in group B. CONCLUSION: Orbital blood flow velocities are altered in patients with Graves' ophthalmopathy and may be detected by colour Doppler imaging. Some of these changes also correlate with the enlargement of extraocular muscles. The increased blood flow velocities in arteries may be secondary to orbital inflammation.

Nucleoside diphosphate kinase (nm23 protein) expression in retinoblastoma.

Forty-two enucleated eyes of 42 patients with unilateral retinoblastoma were studied histologically, including histochemically examination with anti-nm23 polyclonal antibody which does not recognise cDNA but its product. Primary tumours of >15 mm diameter with less evidence of apoptosis and with the most pleomorphic and anaplastic nuclei were associated with an increased risk of distant metastasis, but rosette formation did not discriminate. A high intensity of nm23 staining also indicated a tendency to metastasize, consistent with childhood neuroblastoma but in contrast to findings in carcinoma of the breast, colon and uterine cervix.

Chronic dacryoadenitis misdiagnosed as eyelid edema and allergic conjunctivitis.

PURPOSE: To report the case of a 53-year-old woman with a 2-year history of episodic upper eyelid swelling and nonspecific complaints, who was diagnosed as having allergic conjunctivitis. METHODS: A complete ocular examination, orbital computerized tomographic (CT) scans followed by complete physical and systemic examinations. RESULTS: The results of physical and systemic examinations were unremarkable for systemic lymphoma and a primary focus of cancer. The results of the ocular examination were normal. CT scans demonstrated well-defined lesions bilaterally with a homogeneous internal structure in the lacrimal gland fossa, which suggested a diagnosis of chronic dacryoadenitis. The differential diagnosis included lymphoma and orbital metastases. The patient refused a biopsy and was started on a tapering dose of 60 mg oral prednisolone daily. The follow-up CT scans 1 month after cessation of 6-week oral corticosteroid treatment showed near complete resolution of the orbital lesions. CONCLUSION: This case demonstrates that orbital inflammation can be misdiagnosed as refractory allergic conjunctivitis.

Quantitative CT of the orbit in Graves' disease.

In order to determine the value of quantitative CT of the orbit in patients with Graves' disease, we clinically examined 174 orbits of 87 patients with Graves' disease and evaluated them by CT in respect to the density and size of the extraocular muscles, the globe position and the width of the optic nerve-sheath complex. We also determined the normal ranges for density of extraocular muscles in 200 normal orbits of 100 patients for comparison. Normal ranges for the density of extraocular muscles were (mean +/- 2 SD) medial rectus, 28-63 HU; lateral rectus, 24-78 HU; inferior rectus, 20-64 HU; superior muscle group, 28-62 HU. 51 of 77 (66%) patients with Graves' disease had extraocular muscle density changes. Some extraocular muscles showed fatty infiltration on CT. 50 of 87 (57%) patients had at least one enlarged extraocular muscle, 47 (54%) patients had exophthalmos and 59 (68%) patients had either exophthalmos and/or extraocular muscle enlargement. A diagnosis of Graves' ophthalmopathy was made in 69 of 87 (79%) patients using CT and in 50 (57%) patients by clinical examination. We conclude that quantitative CT imaging of the orbit with evaluation of the size and density values of extraocular muscles and the globe position may be very helpful in detecting ophthalmopathy in patients with Graves' disease.

Malignant melanomas of the iris.

The recognition of iris melanoma is important because a number of benign lesions clinically resemble these tumors. In this article, the epidemiological, clinical and histopathological features, treatment modalities, and prognosis of 41 iris melanoma patients, seen between 1964 and 1996 were evaluated. Of the patients, 20 were men and 21 women. Their mean age was 44.6 years. After determining the size, localization, and extension of the tumor, the management of choice was observation in 9, sector iridectomy in 15, iridocyclectomy in 6 and enucleation in 11 of the patients. During the follow-up, enucleation was also required in 6 and iridocyclectomy in 1 of the 7 patients who were in the observation or sector iridectomy group initially. Histopathologic examination revealed spindle cell in 27, mixed cell in 6 and epithelioid cell type melanomas in 2 of the 35 cases who underwent iridectomy, iridocyclectomy, and/or enucleation. The mean follow-up was 3.2 years and the mortality rate was found to be 2.4% during this period. One patient who died of metastases had epithelioid cell type melanoma.

Effect of pre-enucleation irradiation on the survival of patients with uveal melanoma.

The effect of pre-enucleation irradiation on the survival of patients with uveal melanoma was investigated in 140 patients. Of the patients, 42 received pre-enucleation cobalt external radiotherapy 2,000 cGy, in five fractions between 1981-1991. The control group consisted of 98 patients with uveal melanoma treated by enucleation alone between 1964 and 1994. The great majority of tumors in each group were confined to the choroid. The mean follow-up period was 58.3 months in the irradiated group and 61.6 months in the enucleation group. A comparison of the Kaplan-Meier survival curves of the patients managed by pre-enucleation irradiation and enucleation indicated no significant difference in survival between the groups. After 5 years of follow-up, the survival rates for the preoperatively irradiated group and the control group were, 86.5 and 86.8%, respectively. In both groups, women had a significantly better survival than men. It is more likely that pre-enucleation irradiation does not appear to improve survival in patients with uveal melanoma. The reason for this may be the micrometastases that occur before treatment.

Focal dermal hypoplasia (Goltz's syndrome).

A 17-year-old female with Goltz's syndrome was examined because of visual acuity loss in her right eye. Ocular examination revealed microcornea, iris, choroid and optic disc coloboma in the right eye. There were several erthematous and hyperpigmented areas on the body. Magnetic resonance (MR) imaging of the orbits and brain demonstrated right optic nerve hypoplasia and diffuse cortical and cerebellar atrophy. Skeletal manifestations were short stature, scoliosis, syndactyly, clinodactyly, and osteopathia striata. Dental defects included hypodontia, developmental defects, and malocclusion. There were multiple papillomatous lesions on the lids and perioral skin and the nose was asymmetric. Her mental development was apparently normal. She had left bifid ureter and renal pelvis, scant hair on the pubic and genital region, and poor breast development. Histopathologic examination of the biopsy taken from a characteristic skin lesion revealed attenuated epidermis, hypoplastic dermis, and subcutaneous fat close to epidermis. Immunofluorescence staining was negative for IgG, IgM, IgA, C3, C4, fibrin, and albumin. Ultrastructural examination showed that no viral particles were present. Prometaphase chromosome analysis revealed a normal 46, XX female karyotype. Cortical and cerebellar atrophy can occur in a patient with Goltz's syndrome.

Causes of enucleation: a clinicopathological study.

BACKGROUND: Enucleation is an approach used for unresponsive end-stage ocular disease often resulting in blind, painful or cosmetically unacceptable eyes. METHODS: We reviewed the clinicopathological data on 3506 enucleations performed over a 50-year period, 1945-1995. Histopathological data were divided into eight groups according to the causes leading to enucleation: trauma, phthisis, corneal disease, inflammation, vitreoretinal disease, glaucoma, tumors and infections. RESULTS: The study considered 3506 enucleated eyes of 3482 patients, 2467 (70.8%) males and 1011 (29.1%) females (4 sex unspecified). The z-test showed there were significantly more enucleations in males for phthisis (p < 5.05), infections (p < 0.01), trauma (p < 0.01) and inflammation (p < 0.01) and more enucleations for tumors in females (p < 0.01). There were no differences between males and females with regard to enucleations for glaucoma, vitreoretinal and corneal diseases (p > 0.05). The 0-9 years age group was most frequently affected, accounting for 29.7% of the cases. Patients aged less than 30 years constituted 53.6% of all enucleations. The primary or underlying causes leading to enucleation were tumors (1185 eyes, 33.8%), phthisis (587 eyes, 16.7), glaucoma (561 eyes, 16.0%), vitreoretinal diseases (320 eyes, 9.1%), infections (259 eyes, 7.4%), corneal disease (229 eyes, 6.5%), trauma (209 eyes, 6.0%) and inflammation (156 eyes, 4.4%). Time trends in enucleating eyes with different causes showed the number of enucleations for phthisis, infections, corneal diseases, trauma and inflammations had dropped during the ten-year period 1986-1995 compared to 1976-1985 (z-test, p < 0.01). There were no real changes in enucleations for glaucoma and vitreoretinal diseases and there was an increase in the number of enucleations for tumors (p < 0.01). CONCLUSIONS: Improved diagnostic and therapeutic methods, widespread use of photocoagulation in vascular disorders and vitreoretinal surgery in traumas, effective antimicrobial treatment, increasing use of corticosteroids and immunosuppressants, have contributed to the decreasing frequency of enucleation. Tumor patients generally presented late with advanced tumors totally filling the eye, not salvageable by other non-invasive treatment methods. Prompt diagnosis of intraocular malignant tumors (retinoblastoma and malignant melanoma) may reduce the need for enucleation.

Congenital symblepharon (abortive cryptophthalmos) associated with meningoencephalocele.

An 18-year-old male patient was first seen with right congenital symblepharon (abortive cryptophthalmos) and right frontal meningoencephalocele. There were no other affected members in the pedigree. Computed tomograms revealed that the right orbital roof was absent. Apart from a right harelip on the affected side, there were no other systemic abnormalities. The eye had light perception only. The upper eyelid connected with the globe and the cornea was totally opaque. Echographic studies showed that the eye was improperly developed. Electroencephalography detected slow-wave activity over the right frontoparietal region.

Anterior segment ischemia following pterygium surgery.

A 60-year-old woman developed anterior segment ischemia 1 week after an uneventful pterygium excision in the left eye. Corrected visual acuity fell from 20/20 to 20/200. Ophthalmic examination found keratic precipitates on the corneal endothelium, ++ cells in the aqueous humor, and necrosis of the lower half of the iris with posterior synechiae resulting in a fixed and distorted pupil. On therapy of topical corticosteroid eyedrops hourly and atropine eyedrops three times a day, the iridocyclitis resolved in 2 weeks. At the final examination 3 months after the surgery, the corrected visual acuity was 20/20. The atrophy of the lower half of the iris and posterior synechiae in the lower half of the pupil, giving the fixed and distorted pupil, were noted as sequelae. Iris fluorescein angiography revealed filling defects in the lower half of the iris but no leakage from iris vessels. Systemic evaluation was unremarkable except for mild hypertension. Doppler studies of carotid, ophthalmic, and central retinal arteries were normal. Mitomycin C, beta-irradiation and rectus muscle fixation sutures were not used. Only conjunctival dissection or episcleral cauterization were seen as possible causes of interference with the anterior segment blood supply. We believe this is the first report of anterior segment ischemia following pterygium surgery.

Secondary orbital tumors.

The authors reviewed their experience with 524 secondary orbital tumor cases diagnosed histopathologically during 1963-1993. Secondary tumors constituted 48.0% of all orbital biopsies during the same period. There were 186 (35.5%) cases with eyelid tumors, 146 (27.9%) cases with intraocular tumors, 137 (26.1%) cases with conjunctival tumors, 26 (5.0%) cases with nasopharyngeal tumors, 22 (4.2%) cases with sinus carcinomas, 3 (0.6%) cases with intracranial meningiomas, 3 (0.6%) cases with esthesioneuroblastomas, and 1 (0.2%) case with chordoma. The three most frequent tumors making secondary orbital invasion were basal cell eyelid carcinoma (129 cases; 24.6%), squamous cell conjunctival carcinoma (125 cases; 23.8%), and retinoblastoma (123 cases; 23.5%). Squamous cell carcinoma, from various sites of origin, was the most frequent histopathologic tumor variant, accounting for 215 (41.0%) cases. Exenteration was performed on 334 (63.7%) of 524 cases with secondary orbital invasion. The ignorance of many lid and conjunctival lesions until the advanced stages, which could otherwise be easily treatable, caused blindness and life-threatening complications under our conditions. Orbital invasion from ocular retinoblastoma and uveal malignant melanoma led to a markedly poor prognosis, again related to the late presentation of many patients. Lack of health consciousness, inadequate primary surgery, and/or insufficient follow-up were the main reasons for secondary orbital invasion in many tumor cases.

Papillary adenocarcinoma of the ciliary body simulating retinoblastoma.

PURPOSE: To report a 2 1/2-year-old boy who had papillary adenocarcinoma of the ciliary body that simulated retinoblastoma. METHOD: Initially treated for congenital glaucoma, the patient was referred with a white mass involving the iris, chamber angle, and ciliary body. RESULTS: Enucleation of the right eye, which was initially diagnosed as retinoblastoma, showed a papillary adenocarcinoma of the ciliary body epithelium involving the posterior chamber, iris, anterior chamber, and trabeculum. CONCLUSION: Adenocarcinoma of the ciliary body must be included in the differential diagnosis of tumors originating from the ciliary body in young children.

A linkage analysis in two families with bilateral retinoblastoma.

Using polymerase chain reaction (PCR) amplification from blood samples, Xbal and BamHI polymorphisms were analyzed in two families with bilateral retinoblastoma. In one of the families it was predicted using the BamHI polymorphism that the 200 bp allele co-segregates with the disease. This family was uninformative for Xbal polymorphism. The second family was uninformative for both Xbal and BamHI polymorphism.